For unseasoned hematology/oncology fellows, approaching the discussion of a cancer diagnosis with a patient can be among the most stressful and intimidating aspects of the job. However, meticulous preparation encompassing the patient’s disease characteristics and potential treatment course options before their initial visit, as well as personalized communication, can make the task much more manageable for new fellows, according to Ashish Saxena, MD, PhD.
“[Discussing a new cancer diagnosis] is very daunting,” Saxena said in an interview with Oncology Fellows. “Before fellowship, you don’t get a lot of exposure to the details of oncology. [During your training], your job usually includes calling the oncologist, which is different from some of the other specialties where you may get into a detailed discussion about heart or gastrointestinal disease. It’s understandable to feel a little overwhelmed when you’re starting out, but you need to prepare as best you can in order to understand where the patient is coming from. Don’t take things personally and realize you’ll pick up [knowledge] with repetition.”
Saxena is the Madeline and Stephen Anbinder Clinical Scholar in Hematology/Oncology and an associate professor of clinical medicine at Weill Cornell Medical College, as well as an associate attending physician at the NewYork-Presbyterian Hospital, both in New York, New York.
In the interview, Saxena discussed how he walks through a new cancer diagnosis with a patient, advice for new fellows when discussing a new diagnosis, and how to tackle common questions from patients during your initial encounter with them.
Oncology Fellows: What structure have you found the most useful when approaching new patient diagnoses?
Saxena: When you have a [patient with] a new diagnosis, there are certain questions you want to ask so you can determine how you’re going to treat them. You want to know what type of cancer it is, and these days that involves a lot of [details]. You’re not just finding out if it’s lung cancer, breast cancer, or leukemia, but also getting much of the other information that is needed, which is often molecular [in nature]. I treat patients with lung cancer, and knowing what mutations their disease has and [any] other molecular characteristics can determine their treatment course.
Another question, particularly for [patients with] solid tumors, is what stage is the cancer? We manage cancers at different stages differently. How advanced is it?
Finally, [we want to know] the characteristics of the patient. Do they have a lot of comorbidities? Do they have other things going on, medically or socially, and how are those going to affect the treatment that we give? [For example], for a patient with trouble breathing and heart failure, you’re going to treat them differently than someone who is completely functional and has an ECOG performance status of 0 without any symptoms.
What is the most important message to convey to patients on their first visit?
Patients are usually shocked to have a cancer diagnosis. They oftentimes may have gotten their diagnosis before they see you, but without a lot of the details of what it means and what the outcomes could be. They’re usually told that they have cancer and will be sent to an oncologist, but that’s it.
One of the most important messages is [letting the patient know] that, for the most part, we can treat them. At this time, it’s very rare that we’ll say there’s nothing we can do for them. [Patients] also need to have an understanding and a realistic expectation of what the goals of treatment are.
[For example], they should know what treatment we’re going to give [and whether it’s being given with curative intent]. So, it may be rough, but our goal is cure. [On the other hand], they should know if we’re likely not going to cure them. That doesn’t mean we can’t do anything, but the goals of the treatment are to make them live longer, make them comfortable, and extend their life.
What is your primary advice for fellows who are walking into their first new patient encounter in the clinic?
Having as much information [as possible] before you go in is important. It’s also important to have a sense of what the treatment options could be.
You should also be prepared for a lot of questions, [some of which] you may not be able to answer. Even the attending [may not be able to] answer all [the patient’s questions] on their first visit. Be up front with the patient and say that “we don’t have this answer right now” or “I don’t know if I will be able to answer that.”
You also need to understand the patient’s perspective. They’ve gotten this devastating diagnosis, and patients react to that in different ways. Some are quiet and don’t want to talk at all. Some may come off as aggressive or can be accusatory toward you. It’s important to understand that they’re coming from their own place and not take things personally.
How should new fellows approach fielding common questions from patients such as “how long will I live” or “which treatment is better?”
Regarding the “how long am I going to live” question, I always say that I don’t know because every patient is different. Some patients will want to know just the statistics. They’ll say, “I know you can’t tell me, but what are the odds?” Knowing the literature [and] the median overall survival is helpful for some patients. [A big] part of it is knowing the literature enough to be able to answer some questions, such as what’s the life expectancy with this treatment?
In terms of what’s the best treatment, that is also usually based on literature and clinical studies. Sometimes we will say, “We don’t have a best treatment, but these are the options, and we don’t know which one is better, but they’re all [effective].” Or we can say that “this treatment has been shown to be better than another, so I would recommend this treatment for you,” or that I wouldn’t recommend it because I don’t think you can tolerate the adverse effects, even though it may be what I would give you normally. Knowing the background and the literature of different treatments helps answer some of those questions.
What is the current standing of training for fellows in terms of discussing a new diagnosis?
Fellowship programs are different from one another. Some include much more on-your-own training. For some programs, fellows come in and are expected to have figured this out already. When I’m training fellows, I give them the overview [of the patient’s situation before the initial visit] and then refresh them each time. For me, the repetition was helpful, [so I like to provide that to the fellows]. As you keep doing it [repeatedly], each new patient visit becomes easier because you remember that you’re supposed to know these things, [since] these are the things that I’m going to probably get asked [about].